This week we went over some Case Studies, and applied a SMART model to them with the aim of helping the client. I really enjoyed learning about the SMART model, and having a quick look at some of the other models and systems out there. We’ve learned how to ask questions, resist the pushing of our boundaries, how to be present in the room and gently challenge clients, and we’ve learnt a great deal about ourselves, and now I feel like we’re getting into the deep and fascinating stuff.
The fact that we only had a few paragraphs of information about each case study rather than an actual person in front of us for this activity underlined the importance of listening for the client’s agenda rather than working from my own frame of reference. With so many details missing, and without the ability to ask the clients for more details, I was forced to fill the gaps with my own biases and speculative guesswork. This results in everyone’s conclusions being vastly different to everyone else’s; but then I think that even in regular counselling where you do have a real person in front of you, every counsellor does things a little bit differently, opens with different questions, pursues different trains of thought, and picks up on different nuggets of interest.
Case Study 1 – Tom
Tom’s father (Des) died from a heart attack five months ago. Tom is 25 years old and has been estranged from his father for over five years.
His father’s death has had an unexpected impact on Tom, who finds himself exhibiting very intimidating and aggressive behaviour towards his colleagues and friends. Tom had always been very secretive and introverted so this is significantly out of character for him. He assumed that this behaviour is in some way connected to his father’s death but is not sure how to stop it.
Tom has not shed a tear over his father’s death and is mostly concerned for his mother and her grief. Tom’s father was a very intimidating man who ruled the house through a fear campaign. Despite this, Tom’s mother stayed by his side until the end.
Although Tom has not spoken with his father for over five years he has had moderate contact with his mother. Tom is by nature an emotionally withdrawn man, who has difficulty expressing his emotions – a consequence he has surmised form a childhood of not letting his father see that he’s hurt him or give him the satisfaction of seeing him cry.
My SMART plan for Tom would be to see a counsellor that specialised in grief (Specific), once a week for six weeks (Time-bound), measuring his mood and behaviour over those six weeks (Measurable). I believe Tom is in the anger stage of the Kubler-Ross cycle of grief (Relevant), and I think that exploring his feelings around his father’s death and the relationship they shared would go a long way to providing him with closure, explaining his out of character behaviours, and grant him the ability to move on, a goal which I believe is (Attainable). Seeing a counsellor would also be a good place for Tom to explore some of the emotions he has bottled up over the years, and may even lead to him being less emotionally withdrawn in his day to day life, and give him the confidence to improve his relationship with his mother. It depends on whether Tom’s only objective would be to move on from his father’s death, or if he sees this as a catalyst for greater change.
There are a lot of occasions in each case study where I would like to delve deeper into the details about certain events or relationships, or explore what was going on in the people’s lives when their behaviour changed to see if we can work out the causes of their behaviour changing. Going back through your life and finding out the reason why you do certain things, or react in certain ways can be therapeutic and revealing, often leading to an “a-ha” moment. As a counterpoint to that, simply knowing which event was likely to have caused a change in behaviour doesn’t necessarily stop the behaviour.
In some cases, like this one, it is obvious what has caused the change in a person, in others it is not. In some cases it may have happened in early childhood before conscious memories are formed, or maybe the memory of the event may be repressed. In this case, Tom assumed his behaviour was connected to his father’s death on his own, without the help of a counsellor, but he is not sure how to change the behaviours it has caused. It could be that he is unconsciously trying to fill the void left by his intimidating, fear inducing father, or maybe he is lashing out because he is upset that they had not spoken in five years. Either way, working with a counsellor to deeply explore his issues would help.
Case Study 2 – John
John was devastated when he arrived at the hospital and was told it was too late to see his wife, Gayle. None of the resuscitation attempts had worked. John felt it was all his fault; he could have prevented this if only he had spent more time at home with his family rather than working all the time; he could have noticed the warning signs earlier and taken her to the doctor. He had worked so hard to give Gayle and Ryan (their only child) the lifestyles they deserved. Now he was left with no wife and a son he hardly knows. He feels extremely isolated and doesn’t know what to say to Ryan as he doesn’t want to make the situation worse. The last thing John wants is for his son to see him vulnerable.
John went to church occasionally when Gayle managed to convince him. He felt that his wife being taken away was a higher power trying to teach him a lesson about life.
John does not have many friends outside of his workplace and even those are more like associates. Gayle was his best friend.
My SMART plan for John would be to take up some kind of physical pursuit as a hobby with Ryan (Specific). My reasoning for this is manifold. Firstly, the physical activity would hopefully ensure that John does not allow himself to give up on himself physically, as often happens. It would be an opportunity for John and Ryan to get to know each other (Relevant) and catch up at a specific time and day of the week, every week, something that I hope they would both come to look forward to and cherish. I think building up their relationship as father and son would be the most important thing, as they are all each other have now. It would also help John feel less isolated.
The goal could be measured over time with a series of questions about how John feels their relationship (Measurable). At first they could be working together towards a specific date (Time-bound); some kind of competition or tournament like a marathon or a father-son relay race. The goal would not be to win, but to take part together (Attainable). After the competition, and thus the (Time-bound) element of the SMART goal, it would be great if they continued.
Case Study 3 – Jared and the Benton Family
Jared Benton is a 15 year old boy who has reluctantly agreed with his parents’ request to come to counselling because of his aggressive behaviour at home and at school. Jared’s Dad, Andrew, and stepmother, Melissa, are worried because his recent conduct at school has led to him being permanently excluded. Jared now goes out during the day and argues with his Dad and stepmother if they ask where he is going. He returns in the evening and spends time on his computer. If he is disturbed, he becomes very hostile and swears and shouts at Andrew and Melissa. Andrew feels that Jared has no respect for Melissa at all and is aware that Jared is less aggressive when he is home, although Jared still has frequent outbursts.
Melissa feels she has no control over Jared and is worried about being home alone with him as when he gets mad at her, he has started to lash out and throw things. Jared concludes that some of the aggression builds because his stepmother is constantly nagging at him to get off the computer and this puts him off his game.
The situation escalated at home a couple of weeks ago when Jared became so frustrated by his stepmother affecting his concentration on his computer game that he threw the console and broke it, amongst other things in his room. Jared was upset by this afterwards as he felt he had no control over his aggression and frustration and has broken valuable belongings that he saved for by working part time with his Dad over the school holidays.
Jared does not want to go back to school as he gets too annoyed at the teachers telling him what to do all the time.
Andrew and Melissa mention that he was never an aggressive child and only started being hostile a few years ago. They are extremely concerned about Jared’s future.
I think this one is tricky, because while Jared has reluctantly agreed to come to counselling, he may not want to co-operate fully with the process, which may make things run less than smoothly. However, assuming that he gets into the swing of things and sees some of the benefits for himself after a session or two, I would suggest that his SMART plan for him would be to go and work part-time with his Dad (Specific) for eight weeks (Time-bound). Now that he has been excluded from school and fills his days with nothing in particular, this would be possible. The last time he worked with his Dad he bought himself some nice things that he destroyed during an outburst, he could replace them if he earned some more money by working with his Dad. This also proves that working with his Dad is (Attainable), as he has done it before.
Over the eight weeks, it would be important to measure how Jared feels about himself, things like his personal perception of himself, his self-worth and his self-esteem, as well as how he feels about his Dad, and their relationship (Measurable). After the eight weeks, he would have work experience, some money in his pocket, and hopefully a new-found sense of belief in himself. If he performed well, then maybe his Dad could find a full-time or more permanent position for him. This is also what makes this SMART goal (Relevant) – working with his Dad would rebuild their relationship, which I think is at the centre of this whole problem.
I would like to know a great many more details than are included in this case study though, for example, what happened to Jared’s birth-mother, what happened around the time he started becoming hostile, and what his relationship with his step-mother is like, aside from the times when she nags and he is aggressive.
Case Study 4 – Pamela
Pamela is very proud of her career. She explains how she has worked harder than those around her in her male dominated industry to get where she is today. She has had to sacrifice a lot over the years but Pamela is adamant that those sacrifices were worth it – and so are the long working hours.
She looks around at what her female friends have though and sometimes is a little jealous that they have settled down and had families.
Pamela is single and very independent. She describes herself as a perfectionist and she is aware that she agonizes over being “good enough” at work. Her social life was one of sacrifices. She only has a few close friends left; she doesn’t feel as though she can associate with most people.
She has come to counselling because her parents and friends have noticed that over a period of months, she has lost a lot of weight and Pamela says they have described her as looking “ill”.
Pamela knows she has always been fastidious about her diet but admits that this has become an obsession and food is starting to become abhorrent to her. She has been existing on one small meal at lunch time, so her co-workers do not suspect that she is severely limiting her food intake. Recently though, she has only been eating an apple at lunch time. She says she keeps going by drinking coffee; this gives her the energy to tackle the latest project.
With the help of a nutrition expert, I would base the SMART plan around her eating habits (Specific) as they are not at all healthy, and are definitely contributing to her poor mental and physical state. Whilst I don’t know exactly what her eating plan would look like, I think it would be better for her to eat a more varied diet rather than just an apple now and again! I would suggest that she finish work an hour earlier, so that she can go home and cook something nutritious for herself. Although she is proud of her career, she does realise that something is wrong with her situation (this makes the goal Attainable – she wants to change), and an hour less at work a day that she can spend on self-care looking after herself would be beneficial (Relevant).
I don’t know how long it takes to make a difference in this respect, but after a determined amount of weeks (Time-bound) the nutrition expert could review her progress and see what, (if anything) needs to be adjusted. Continual monitoring of any and all SMART goal systems are the key to making them work efficiently. Her weight and bodily circumference would be physical markers of progress, and she could also keep a record of her mood and energy (Measurable). I would also suggest Pamela attend regular counselling to work through her regret and jealousy. It is not healthy to dwell on those emotions.
To conclude, overall I think that models and systems, as measurable ways for counsellors and clients to set and achieve goals, are immensely powerful tools to make use of. They can provide focus and can be very useful for monitoring a client’s needs and recognising any changes in their behaviour which affect the working contract, as well as the therapeutic relationship as a whole. It is important to notice these changes in a client’s needs or behaviour, especially when using a model such as SMART – if a process is not working for a client then it should be looked at, discussed, and possibly changed, to prevent the client from feeling like they are on the wrong track.
Evaluating these case studies caused me to rethink my example of a working contract and I made some changes that I thought would be useful. First, I made the font smaller so I could fit it all on one page. I think it’s important to have it all on one sheet, so as to not overload the client with pages and pages of information. They are there to get all the stuff out of their heads, not there for me to put more stuff in there. I included more details about me, specifically my qualifications and membership of a professional body. Because of this, I was also able to include the complaints procedure, something that I hope none of my clients would ever need to make use of, but it is an ethical thing to provide. I would like to continually evolve my personal statement in “Our Aims” – I like “I will accept you and your way of being” but I do think it could be a bit less wishy-washy.
I expanded the confidentiality section to include that if I felt a client was in immediate danger I would contact their GP. This was in response to the Case study 1 – Tom when I felt he could become a little suicidal, in that if I felt their behaviour changed in a negative way then I would invoke this part of the working contract to help them. I expanded the time-keeping section to include asking for as much notice as possible, something that came to mind with Case study 3 – Jared because I felt that because he didn’t necessarily want to come to counselling, he could just not turn up to an appointment. I put in there about cancelling the contract at any time to let the client know that they do have a lot of control and that if their needs change then we can be flexible and alter how often we see each other or if we stop altogether. I would always prefer to agree this mutually, but if a client feels they must stop attending, then it is what it is.
